Pediatric VAD Recovery: 26% Explant Rate With Standardized Program

A standardized ventricular recovery program at Children’s Hospital of Philadelphia (CHOP) has shown remarkable success, enabling 26% of children with ventricular assist devices (VADs) to have them explanted – a rate significantly higher than the national average of 4% to 6%. This promising development offers renewed hope for young patients awaiting heart transplantation and suggests a potential pathway toward heart function recovery, rather than solely relying on VADs as a bridge to transplant.

The program, detailed in a recent publication in the Journal of the American Heart Association, centers around a proactive approach to identifying and supporting potential heart recovery in children supported by VADs. Dr. Jonathan B. Edelson, medical director of the Heart Transplant and Ventricular Assist Device Program at CHOP, emphasized the shift in mindset. “If you look at the national incidence of recovery and explant in children, it’s somewhere around 4% to 6%. Having an incidence five times as high as that is really encouraging, and it raises the possibility that recovery is a real option for many of these children,” he told Healio.

Four Pillars of Recovery

The CHOP program is built on what researchers describe as four key pillars. First, a fundamental shift in perspective – viewing every child with a VAD as a potential candidate for recovery. Second, the consistent application of goal-directed medical therapy, utilizing medications known to promote positive heart remodeling. Third, a standardized and protocolized surveillance process to consistently evaluate all children for signs of recovery. And finally, a collaborative, multidisciplinary approach involving physicians, nurses, surgeons, and intensive care teams.

VADs, while life-saving, aren’t simply passive support systems. As Dr. Edelson explained, they actively benefit the heart by reducing workload and improving overall body perfusion, allowing organs like the kidneys, liver, and gut to recover. This creates a window of opportunity for the heart muscle itself to rest and potentially regain function. The program leverages this by carefully and gradually reducing VAD support to assess the heart’s ability to function independently.

The study involved 35 patients followed for two years. The median age was 3.1 years, with slightly over a third being female. The underlying causes of heart failure varied, with cardiomyopathy being the most common (60%), followed by congenital heart disease (31%), coronary pathology (6%), and myocarditis (3%). The majority of patients (approximately two-thirds) were supported by the Excor VAD (Berlin Heart), while the remainder used the HeartMate 3 VAD (Abbott). More information on the Excor VAD can be found here.

Assessing Heart ‘Wake-Up’

Catherine M. Montgomery, BSN, RN, CPN, VAD nurse coordinator at CHOP, highlighted the importance of careful assessment during the recovery process. “We use that [VAD] as a tool to continue to assess the work of the heart. So if we turn the VAD down a little bit, One can see how the heart ‘wakes up,’ if you will, and if it’s able to take over that type of output. That can clue us in to see if the heart is ready for recovery.”

Of the 35 patients participating in the program, nine (26%) ultimately had their VADs successfully explanted. These patients had a median age of 1 year and their initial diagnoses included cardiomyopathy, coronary pathology, and myocarditis. Importantly, the children who underwent successful explantation have demonstrated positive long-term outcomes, with only one requiring a subsequent heart transplant and currently doing well at home.

Implications for Pediatric Heart Failure

The success of this program has significant implications for the management of pediatric heart failure. With donor heart availability often limited, the possibility of heart recovery offers a valuable alternative to prolonged VAD support and the waitlist for transplantation. As Montgomery explained to Healio, “Seeing these results in combination with longer wait times for donor hearts, this will continue to be our programmatic approach with our VAD patients.”

Looking ahead, the research team plans to expand the program to other centers, investigate the underlying biological mechanisms driving ventricular recovery, and identify biomarkers or clinical indicators that can predict which patients are most likely to benefit from this approach. “The technology is present to use VADs to promote recovery,” Dr. Edelson stated. “What we need to work on now is changing the mindset and changing the behavior, and seeing VADs as not just bridges to transplant, but tools for myocardial recovery.”

Expanding Access and Understanding Recovery Mechanisms

The potential for broader implementation of this ventricular recovery program hinges on several factors. Standardizing protocols and training multidisciplinary teams will be crucial for ensuring consistent application across different institutions. Further research is needed to refine patient selection criteria and optimize medical therapy to maximize recovery rates.

Understanding the specific biological processes that contribute to heart recovery is also a key priority. Researchers are exploring the role of factors such as inflammation, cellular regeneration, and cardiac remodeling in mediating the positive effects of VAD support and medical therapy. Identifying these mechanisms could lead to the development of targeted interventions to enhance recovery potential.

The team at CHOP is also actively investigating the use of advanced imaging techniques, such as cardiac MRI, to assess heart function and identify early signs of recovery. These non-invasive tools can provide valuable insights into the heart’s response to therapy and help guide treatment decisions.

For more information:

Jonathan B. Edelson, MD, MSCE, can be reached at [email protected].

Catherine M. Montgomery, BSN, RN, CPN, can be reached at [email protected].

You can discover more information about pediatric heart failure and VADs from the Centers for Disease Control and Prevention and the American Heart Association.